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Case study #2: From Control Policy to Comprehensive Family Planning: Success Stories from Finland

Background and rationale for the initiative

Finland has a strong tradition of equity and social justice produced by provision of basic services for all citizens (Hermanson et al., 1994). After the World War II, maternal and child health care services, free of charge, were established. Well-trained public health nurses and midwives, employed by local municipalities, run the services. The low rate of infant mortality, 5,2/1000 in 1992, reflects the high quality of reproductive health services (The Family Federation of Finland, 1994).

In the late 1960s Finland adopted a comprehensive family planning strategy, based on foundations of public health and preventive medicine. The focus of the action moved from control of abortion to prevention of its main cause, the unintended pregnancy.

From control to prevention and safe services

In the 1960s, a legal induced abortion was available mainly on medical, ethical and eugenic grounds. The annual number of legal abortions varied from 5 000 to 8000, but the estimated number of illegal terminations of pregnancies was about 20 000 a year. The number of children per woman had continuously declined during the 1950s and 1960s, from about 3,0 to about 1,9 indicating positive results of more effective fertility regulation already before the implementation of the comprehensive family planning strategy.

A new abortion law came into force in 1970. An induced abortion is available on medical, eugenic and socio-economic grounds up to the 12th week of pregnancy with a permission from one or two doctors. From 12 to 24 weeks, a national board will decide whether a termination of pregnancy is necessary. Socio-economic abortion criteria require the consent of two doctors. However, a girl aged under 17 can have termination of pregnancy with permission of one physician. All induced abortions must be notified to the national abortion register (Gissler et al., 1996).

The comprehensive family planning policy put emphasis both on the easy access to safe termination of pregnancy when needed, and integration of contraceptive counselling with the municipal primary health care. Based on the tradition of the Finnish society, it was seen as a responsibility of municipalities to provide family planning and abortion care. The national health authorities issued detailed guidelines for the provision of safe abortion services and closely monitored the delivery of these services.

The Finnish health care was reorganized in the beginning of the 1970s (Hermansson et al., 1994). The Primary Health Care Act of 1972 prescribed that every municipality had to establish a health centre which provides primary health care services for its inhabitants. A visit to the family planning clinic and the first contraceptive method (for instance OCs for 3-6 months) were, and still are, free of charge. The national health authorities published several detailed guidelines on provision of services and prescription of contraceptive methods.

Finland has a long tradition of well-functioning municipal school health services. In the 1970s, counselling in sexual and contraceptive problems became an important field of work for school health. Young people were supposed to use the family planning clinics of the health centres, as well. Therefore, there was no need for specialized youth clinics to provide contraception counselling for adolescents.

In the abortion debate of the 1960s, the central role of sex education was frequently emphasized. The Finnish comprehensive school covered all children between seven and sixteen years. In the 1970s, sex education was integrated to the curriculum of the comprehensive schools.

In 1978 the Ministry of Social Affairs and Health set up a committee to evaluate the experiences and draft proposals for a revision of the abortion law, the guidelines and the provision of the family planning services. The committee proposed minor legislative changes, and prepared detailed recommendations concerning sex education, training of personnel, and contraception counselling.

Implementation of the law: the first success story

Due to the high visibility of a few active opponents, the consequences of the liberalization of the abortion law were carefully monitored by the national health authorities. The opponents claimed that the new law had increased termination of pregnancies.

In the 1960s, the Abortion Committee set up by the Government, estimated that the total number of abortions (legal and illegal) was declining in the 1960s. After the new law came into force, the numbers in official statistics tripled, when all abortions were notified. However, there was no real increase in the total number of abortions. The use of illegal termination of pregnancies soon ended, when a safe and legal abortion was available. Simultaneously the amount of abortion complications registered by hospitals decreased dramatically.

In the 1970s, the municipalities reported every year about the provision of the contraception services to the national health authorities. In 1976, already around 90% of the municipal health centres were providing family planning services. The combination of new contraception technologies (OCs and IUDs) and a municipal family planning clinics quickly diminished the incidence of unwanted pregnancies, and, consequently, the demand for abortions.

The declining trend in the official number of abortions continued after 1973, when the move from illegal terminations to legal services was over. During the period 1976 to 1994 the abortion rate per 1000 women decreased from 16.4 to 7.9. The abortion rate for teenage girls rose during 1973 - 1975, when the rate for women aged 20 to 49 already decreased. After 1975 the teenage pregnancy and abortion rates turned to decline.

In 1979-1981, the changes in public opinions were monitored by national opinion polls, and improvements in municipal family planning activities by smaller surveys. The national guidelines concerning abortions, early diagnosis of pregnancies, and contraceptive counselling, were revised. The declining trend in abortion rates continued. Great majority of the public and health professionals were satisfied with both contraceptive and abortion services.

In the beginning of the 1980s, the abortion debate was over. The liberalization of the law in combination with easy access to safe abortion services and contraception counselling was regarded as a success story. Sexual issues did not have any visible position in the public agenda of Finland.

Education, HIV/AIDS, and eroticism in the 1980s

In the 1980s, the emphasis moved from the services to more general issues of sexuality. National health authorities issued the first detailed guidelines on education for sexuality and human relationships. Simultaneously, a nationwide training programme was organized on that subject to health care personnel, teachers and activists of voluntary organizations. Several information campaigns on wider sexual issues were initiated and partly financed by the Ministry of Social Affairs and Health. Then the HIV/AIDS became a dominant theme of public debates, policies and research on sexual issues.

One of the very first national surveys on adult sex behaviour was carried out in 1971 (Leppo, 1978). Unfortunately, the research on sex issues did not achieve permanent position at the research institutions. A lack of recent research on sexual behaviour became obvious in the 1980s, when HIV/AIDS challenge revitalized the social science interest in sexuality. A new era of the Finnish sex research was started by surveys among university students, school children, and adults, to mention the most prominent projects (Kontula et al., 1992; Kontula & Haavio-Mannila, 1995; Rimpelä et al., 1992; Kosunen 1996) .

Increasing research activity coincided with rising demand for lay and professional literature on sexual issues, partly created by the HIV/AIDS publicity. A team of social scientists and national health promotion authorities showed remarkable skills in dissemination of new research findings to public via mass media. Research results were popularised in reports published by the Ministry of Social Affairs and Health ('Erotism and health' in 1989, 'Religion and health' in 1990, and 'Jealousy and health' in 1991) as well as in several books published by commercial publishers.

In 1987, the health authorities started a massive information campaign to prevent HIV/AIDS (Tikkanen & Koskela, 1992). Besides the mass media information, a core element of the campaign was an illustrated magazine containing information about the prevention of STDs and sexual issues in general, a letter to the parents, and a condom. In 1987, the magazine was mailed to the home address of all 16 to 21 year-olds, and from 1988 onwards a revised magazine was annually mailed to all 16 year-olds.

After the initial shock it was seen, that number of new HIV/AIDS cases stayed at an exceptionally low level (Tikkanen & Koskela, 1992), and HIV/AIDS started to loose its momentum in the public agenda. Statistics on abortion and STD showed declining trends. Several research reports from the second nationwide survey on sexuality (Kontula & Haavio-Mannila, 1995) evoked an exceptionally large mass media activity, larger than any other Finnish research program ever.

Teenage pregnancies: the second success story

In Finland, teenage sex never became that hot a topic as in many other countries. Sex education and family planning was integrated into the curriculum of the comprehensive school. In the liberal sexual climate, there was no strong opposition to increase sex education. School health services guaranteed an easy access to contraceptive and abortion counselling as well as contraceptive prescriptions when needed. Until the mid-1980s, teenage pregnancies were not yet defined as a specific problem, and the needs of adolescent population were dealt with in terms of general family planning policy.

A numeric goal for reducing teenage abortions was set up for the first time in 1983: the numbers were to come down by at least 7% per year. The proposals by the Advisory Committee for Health Education were combined with the momentum created by the appearance of HIV/AIDS. A joint initiative by the national health authorities, youth researchers and the Family Federation of Finland gradually led to adoption of a wide range of activities tailored to the needs of teenagers.

Although prevention of unwanted pregnancies was the major goal, trends in teenage pregnancies were not studied more carefully until in the 1990s (Rimpelä et al., 1992; Kosunen, 1996). They showed even a sharper decrease than the abortion rates. While 49 out of 1000 girls aged 15-19 got pregnant in 1975 (counted as a sum of induced abortions and live births), the figure for 1990 was down 26/1000 and 1994 to 19/1000. Simultaneously the abortion rate has dropped from 21/1000 to 14/1000 and to 9/1000.

Cohort analyses based on adult surveys suggested that the age at initiation of sexual intercourse lowered in the 1970s and early 1980s (Kontula & Haavio-Mannila, 1994). Since then, on the basis of several youth surveys, there are no signs of increasing nor decreasing sexual activity. It seems evident that the declining pregnancy trends in the late 1980s and 1990s cannot be explained by reduced sexual activity. The Finnish experience clearly speaks against the argument that liberal approach to sex education as such increases adolescent sexual activity. (Kosunen, 1996; Kosunen & Rimpelä, 1996a).

The most obvious explanation for success in prevention of teenage pregnancies is more effective contraception. All studies since the early 1980s suggest increasing use of effective contraceptive methods. Use of oral contraceptives (OC) more than doubled from 1981 to 1989. In the 1989 approximately 40% of the 18 year-old girls and nearly 20% of 16 year-olds used OCs. Since then the proportions of OC users have remained more or less unchanged (Rimpelä et al., 1992).

The use of any contraceptive method at first intercourse increased among 15 year-old adolescents between 1986 and 1992. Simultaneously, the percentage of those who did not use any contraceptive method at the most recent intercourse, declined from 28% to 16% (Kosunen & Rimpelä, 1996a).

The increasing use of emergency contraception is probably one of the factors that reduced the need for induced abortions in the 1990s (Lähteenmäki et al., 1995). According to a recent survey among schoolchildren, emergency contraception is well-known. About one of five sexually active 15-16 year-old girls reported that they had at least once used emergency contraception. So far no negative consequences of increasing use of emergency contraception have been recorded.

Health promotion approach to family planning

At the end of 1992, teenage pregnancies and abortions suddenly became a subject of debate in the mass media. The critics claimed that abortion was used as a method of contraception. When the true trends became known, the public debate died out. However, that incidence created a new interest in the evaluation of family planning services.

In the initial assessment made by the expert group of the National Research and Development Centre for Welfare and Health (Stakes) no burning problems were found. However, due to many contextual changes in society as well as changes in health services, a long-term programme 'Family Planning 2000' was launched, with the following themes to be studied more thoroughly: (1) monitoring the effects of the family planning services and educational measures and updating the use of registers and statistics, (2) training and education of health care and social welfare personnel, (3) sex education and counselling for young people, (4) prevention and care of infertility, (5) research and development of family planning services and sex education, both in primary health care and in hospital clinics, (6) the need for legal reforms related to family planning.

The major goal of the 'Family Planning 2000' -program is to apply the lessons from health promotion developments to family planning: a move from strong national guidance to coalitions at municipal and regional level and a move of emphasis from nationwide research projects to numerous action oriented research and development projects at local level.

Lessons learned from the health promotion literature and experience were applied in building up 'family planning expert' coalitions, especially, at the level of basic health, social and education services. Stakes established a team for a three-year term (1994-1996) to initiate the activities needed for revision and updating family planning and other sexual health related services. The process of establishing local and regional coalitions were started in the Province of Central Finland where the main challenge has been to stimulate collaboration between teachers, health professionals, voluntary associations, municipal and provincial authorities, and research and teaching institutions.

As the principal method of work, numerous workshops with professionals working at grassroots level has been organized, to initiate self-assessment of working practices in hospitals, health centres and schools. Stakes has published 'Family Planning 2000' information bulletin, distributed in five to six issues a year to approximately 1000 family planning activists. National workshops and conferences have been focused on updating clinical guidelines. Numerous local research and development activities are proceeding. Close collaboration of several institutions in Central Finland (university, regional administration, regional hospital, nursing school, health centres, voluntary organisations, etc.) is proceeding towards a more formal coalition entitled the Central Finland Coalition of Research and Development in Family Planning and Sexual Health.

During the past to years the main emphasis has been put on strengthening skills and infrastructure of municipal family planning services:

(1) More effective training of all professionals (doctors, nurses, social workers, teachers, etc.) in counselling: Evaluation of sexuality and family planning related training modules of all training institutions, and stimulation of revision of curriculum when needed.

(2) Updating of evidence based national clinical guidelines and regional 'good practice' programs for (i) starting the first contraception, (ii) abortion care, (iii) vasectomies, (iv) prevention and care of infertility, as well as for (v) prevention and care of STDs.

(3) Ensuring quality of services, especially from the consumers' point of view, by implementing routine client questionnaires in all family planning related health and social services.

(4) Strengthening male involvement: Advocating vasectomies as alternative choice in family planning (In 1994 only 598 vasectomies were registered when the number of female sterilizations was 10 929); inviting men to join their girl friends and wives in visits to contraceptive and other family planning services, etc.

The evaluation of the Family Planning 2000 -program is mainly based on qualitative participant observation studies and case studies. In addition, the data collected by the national birth, abortion and sterilization registries will be analyzed more detailed. In April 1996, sexual experiences and views about sex education in schools were investigated by a classroom questionnaire to more than 50 000 adolescents. The study will be repeated in the schools in 1998 and 2000.

Evidence of success

Today, several indicators show remarkable improvements in reproductive health. There are no signs of increasing unintended effects like promiscuity or use of abortion as a contraceptive method. The number of teenage pregnancies as well as abortions has decreased (Rimpelä et al., 1992; Kosunen, 1996). In the international comparisons, the incidences of sexually transmitted diseases (STD), including HIV/AIDS, are low. Moreover, nationwide surveys have shown that the Finns are more satisfied with their sex life than they were in the 1960s (Kontula & Haavio-Mannila, 1995).

From the early 1970s to the mid-1990s the reproductive health greatly improved in Finland, especially among young people. The corner stones behind the success in implementing comprehensive family planning approach were (1) combination of the public health and preventive medicine approaches (2) well functioning infrastructure of the health and education sector, (3) strong and skilful guidance by the national health authorities, and (4) professional attitude of nurses and doctors in municipal health services.

Evaluation

The first evaluation of the Family Planning 2000 Program, launched in 1994, will be carried out in 1997. There are already several positive signs: More and more professionals are joining local and national coalitions, interest in organizing local workshops and participating them is increasing, demand for professional literature about sexuality and family planning is growing, etc. Outcome indicators show positive trends as well. According to preliminary data from the first months of 1996, use of emergency contraception is increasing, declining trend in abortion rate continues, and demand for vasectomies has increased. However, the more permanent impact of the Program on outcome indicators is expected to be seen only later, in 1998 to 2000.

The rationale behind the Family Planning 2000 Program has been debated. The critics point out the positive trends in sexual and reproductive health: Why should Finland still invest in development of family planning services? As presented above, there are no burning problems demanding for an urgent intervention. However, in 1996 almost 10 000 pregnancies are terminated reflecting the fact that more than one out of eight pregnancies are unintended. There are major regional differences in abortions (Kosunen & Rimpelä, 1996b). If all provinces could reach the level of the Province of Mikkeli, the number of teenage pregnancies would decrease by third in the whole country. In the Netherlands, the abortion rate is clearly lower than in Finland, for all age groups approximately 5,5/1000 and for teenagers 4/1000 (Ketting & Visser, 1994).

The challenge for Finland is, by strengthening the skills of all key professionals and by applying modern health promotion strategies to family planning and sex education, to reach the level of Netherlands in prevention of unintended pregnancies. That would mean, once again, a clear empirical demonstration of the power of the comprehensive family planning approach.

References

Hermanson,T. et al. (1993). Finland's health care system. Universal access to health care in capitalistic democracy. Journal of the American Medical Association, 771, 1957-1962.

The Family Federation of Finland (1994). The evolution of reproductive health in Finland. How we did it. Helsinki: The Family Federation of Finland.

Gissler,M. et al. (1996). Declining induced abortion rate in Finland: Data Quality of the Finnish Abortion Register. International Journal of Epidemiology, 25, 376-380.

Ketting,E. & Visser,A.P. (1994). Contraception in the Netherlands: the low abortion rate explained. Patient Education and Counselling, 23, 161-171.

Kontula,O. & Haavio-Mannila,E. (1995). Sexual pleasures: enhancement of sex life in Finland, 1971-1992. Aldershot, England: Gover House.

Kontula,O., Rimpelä,M. & Ojanlatva,A. (1992). Sexual knowledge, attitudes, fears and behaviours of adolescents in Finland. Health Education Research, 7, 69-77.

Kosunen,E. (1996). Adolescent reproductive health in Finland: Oral contraception, pregnancies and abortions from the 1980s to 1990s. Tampere: University of Tampere (Acta Universitatis Tamperensis. Ser A, Vol. 486, Academic Dissertation).

Kosunen,E. & Rimpelä,M. (1996a). Towards regional equality in family planning: teenage pregnancies and abortions in Finland from 1976 to 1993. Acta Obstet Gynecol Scand, 75, 1996 (in print).

Kosunen,E. & Rimpelä,M. (1996b). Improving adolescent sexual health in Finland. Choices (previously: Planned Parenthood in Europe), 25, 18-21.

Leppo,K. (1978). Contraception in Finland in a public health perspective. Helsinki: University of Helsinki. (Population Research Institute, D5 - 1978. Academic Dissertation.

Lähteenmäki,P. et al. (1995). Use of post-coital contraception in Finland is increasing. Planned Parenthood in Europe, 24, 13-14.

Rimpelä,A. et al. (1992). Use of oral contraceptives by adolescents and its consequences in Finland in 1981-1991. British Medical Journal, 305, 1053-1057.

Stakes. (1996). Reproduction and its trends - statistics on pregnancies, childbirths, sterilizations and congenital malformations in Finland. Helsinki: Stakes (Official Statistics Finland. SVT Health 1996:2).

Tikkanen,J. & Koskela,K. (1992). A five year follow -up study of attitudes to HIV infection among Finns. Health Promotion International, 7, 3-9.

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